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State-of-the-Art Conference on Complex Chronic Care: The Research Agenda Fran Weaver, PhD Acting Center PI Todd Lee, PharmD, PhD Acting Center co-PI Center.

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Presentation on theme: "State-of-the-Art Conference on Complex Chronic Care: The Research Agenda Fran Weaver, PhD Acting Center PI Todd Lee, PharmD, PhD Acting Center co-PI Center."— Presentation transcript:

1 State-of-the-Art Conference on Complex Chronic Care: The Research Agenda Fran Weaver, PhD Acting Center PI Todd Lee, PharmD, PhD Acting Center co-PI Center for Management of Complex Chronic Care Hines VA Hospital

2 Prevalence and Impact of Complex Chronic Conditions in the Department of Veterans Affairs (VA) Todd A. Lee, PharmD, PhD Acting Center co-PI Center for Management of Complex Chronic Care Center for Management of Complex Chronic Care Hines VA Hospital Research Assistant Professor Northwestern University

3 Multiple Chronic Conditions Diseases often described and studied in isolation Diseases often described and studied in isolation Many individuals have multiple chronic conditions Many individuals have multiple chronic conditions Increasing appreciation of complexity and interrelatedness of diseases and their management Increasing appreciation of complexity and interrelatedness of diseases and their management

4 Implications of Multiple Chronic Conditions Conflicting recommendations from clinical practice guidelines Conflicting recommendations from clinical practice guidelines Drug-drug interactions; drug-disease interactions Drug-drug interactions; drug-disease interactions Co-occurring conditions can lead to unexpected consequences Co-occurring conditions can lead to unexpected consequences Increased disability Increased disability Lead to deficiencies in care Lead to deficiencies in care

5 Prevalence of Multiple Chronic Conditions in VA Majority of patients using VA healthcare services have 2+ chronic conditions Majority of patients using VA healthcare services have 2+ chronic conditions More conditions associated with higher average annual healthcare costs More conditions associated with higher average annual healthcare costs # Conditions Avg Annual Cost % Total System Costs 0$6484 1$1,9959 2$3, $9,27773 From Yu et al. Med Care Res Rev 2003

6 Mortality by Number of Conditions

7 Clusters of Disease in VA National VHA data used to identify cohort aged 55 to 64 years in 2000 (N=741,847) National VHA data used to identify cohort aged 55 to 64 years in 2000 (N=741,847) ICD-9 codes used to identify presence of 11 chronic conditions and mutually exclusive clusters created ICD-9 codes used to identify presence of 11 chronic conditions and mutually exclusive clusters created ConditionN (%) (%) 5-Year Mortality % Hypertension + Diabetes 47,568(6.4)6.3 IHD + Hypertension 28,154(3.8)6.3 Hypertension + Osteoarthritis 23,692(3.2)2.9 IHD + Hypertension + Diabetes 19,161(2.6)11.1 Hypertension + COPD 11,883(1.6)12.2 Hypertension + Diabetes + Osteoarthritis 9,136(1.2)5.3

8 3 Disease Clusters COPD or Cancer part of cluster

9 Incremental co-morbid effect of COPD and osteoarthritis on five- year crude mortality rates in veterans aged 55 to 64 years Referent condition + COPD Referent condition + Osteoarthritis Referent condition(s) RR 95% CI RR None of the selected conditions , , 0.67 Hypertension , , 0.83 Diabetes & Hypertension , , 0.93 IHD & Hypertension , , 0.94 Diabetes , , 0.80 IHD & Diabetes & Hypertension , , 0.94 IHD , , 0.76 Depression , , 0.84 Cancer , , 0.64 Cancer & Hypertension , , 0.75 Hypertension & Depression , , 0.96 Diabetes & IHD , , 0.99 Abbreviations: RR = Rate Ratio; IHD = Ischemic Heart Disease Mortality Rate

10 Categories of Death in Patients with COPD Category of causes of death in cohort of 25,297 patients with COPD Categories % Circulatory System 33.4 Cancers27.7 Respiratory system 20.5 Digestive system 3.4 Endocrine, nutritional and metabolic diseases 2.8 Genitourinary system 2.2 Other8.9

11 Cause of Death in Patients with COPD Top 7 underlying causes of death in cohort of 25,297 patients with COPD Cause % Lung cancer 15.4 COPD13.1 Chronic ischemic heart disease 12.9 Acute myocardial infarction 7.5 Heart failure 2.5 Pneumonia, organism unspecified 2.0 Emphysema1.8

12 Clusters of Disease and Depression Identified cohort with depression in VHA in FY2003 (N=335,979) Identified cohort with depression in VHA in FY2003 (N=335,979) Created mutually exclusive clusters of disease based on top 30 most prevalent chronic conditions (excluding depression) in VHA (Yu et al., 2003) Created mutually exclusive clusters of disease based on top 30 most prevalent chronic conditions (excluding depression) in VHA (Yu et al., 2003)

13 Number of Chronic Conditions with Depression * Depression Alone is depression without any of the 30 other conditions included when creating clusters

14 Top 5 Clusters of Depression and Chronic Physical Conditions ConditionN(%) Depression + Hypertension 11,948(13.5) Depression + Hypertension + Diabetes 5,222(5.9) Depression + Hypertension + IHD 4,850(5.5) Depression + Hypertension + Arthritis 4,125(4.7) Depression + Arthritis 3,684(4.2)

15 Other Factors Increase Complexity Not simply number of conditions that lead to complex patients Not simply number of conditions that lead to complex patients Patient factors Patient factors Health literacy, social support, socioeconomic status Health literacy, social support, socioeconomic status Health system factors Health system factors Dual healthcare benefit and coordinating care under two benefits Dual healthcare benefit and coordinating care under two benefits

16 Moving Forward OUTCOMES Traditionally Use VA Information Resources to ID patients Earlier Intervention; Tailored Guidelines; Increased Resources Management of Whole Patient Improved Model for Complex Chronic Care Patients IMPROVED OUTCOMES Diabetes case management Depression Rx

17 Summary Patients with complex chronic conditions are the rule rather than the exception in VA Patients with complex chronic conditions are the rule rather than the exception in VA Need better understanding of these patients, best management strategies and their outcomes Need better understanding of these patients, best management strategies and their outcomes VA presents unique opportunity to begin to build evidence for appropriately managing complex chronic care patients VA presents unique opportunity to begin to build evidence for appropriately managing complex chronic care patients

18 Complex Chronic Care Agenda Fran Weaver, PhD Acting Center PI Center for Management of Complex Chronic Care Hines VA Hospital Research Associate Professor Northwestern University

19 SOTA 2006 VA Research & Development hosted a SOTA in Sept in Arlington, VA VA Research & Development hosted a SOTA in Sept in Arlington, VA Synthesize what we know about managing care for patients with complex chronic illnesses Synthesize what we know about managing care for patients with complex chronic illnesses Develop policy recommendations for VA and larger health community re: improved clinical care models and management strategies Develop policy recommendations for VA and larger health community re: improved clinical care models and management strategies Develop a research agenda to address gaps Develop a research agenda to address gaps

20 Workgroups Identifying the patient with complex chronic illness Identifying the patient with complex chronic illness Self-management for patients with complex chronic illness Self-management for patients with complex chronic illness Developing the evidence and knowledge base for managing patients with complex chronic illness Developing the evidence and knowledge base for managing patients with complex chronic illness Improving systems to manage complex chronic care Improving systems to manage complex chronic care Informatics and complex chronic care Informatics and complex chronic care Linking system and patient strategies for managing complexity Linking system and patient strategies for managing complexity

21 Identifying the Complex Patient A patient for whom clinical decision making and care processes are not standard or routine A patient for whom clinical decision making and care processes are not standard or routine e.g., conflicting guidelines, exceptions needed because of homelessness, caregiver support e.g., conflicting guidelines, exceptions needed because of homelessness, caregiver support Need for considering multiple elements of complexity: medical, biological, genetic, socioeconomic, cultural, behavioral, environmental Need for considering multiple elements of complexity: medical, biological, genetic, socioeconomic, cultural, behavioral, environmental Focus on identifying characteristics of high risk cohorts or clusters Focus on identifying characteristics of high risk cohorts or clusters

22 Self-management Barriers to self-management may be even greater in complex patients Barriers to self-management may be even greater in complex patients Patient: prioritizing multiple demands, individualized plans, new technology Patient: prioritizing multiple demands, individualized plans, new technology Provider: inadequate time & resources, lack of appropriate treatment guidelines Provider: inadequate time & resources, lack of appropriate treatment guidelines System: lack of reimbursement for self-management support tasks System: lack of reimbursement for self-management support tasks Test new care delivery models – group visits, peer support, telemedicine, MyHealtheVet Test new care delivery models – group visits, peer support, telemedicine, MyHealtheVet

23 Developing an Evidence Base Improved research methods (e.g., RCT that include complex patients) Improved research methods (e.g., RCT that include complex patients) Develop guidelines that address patients with complex conditions Develop guidelines that address patients with complex conditions Educate/train professionals re: complex Educate/train professionals re: complex Greater use of multidisciplinary teams Greater use of multidisciplinary teams Engage patients and caregivers Engage patients and caregivers

24 Improving Systems High quality achieved through maximizing functional status, quality of life and patient satisfaction High quality achieved through maximizing functional status, quality of life and patient satisfaction Reduce adverse events, eliminate unnecessary care, and enhance patient safety Reduce adverse events, eliminate unnecessary care, and enhance patient safety Patient-centric orientation – foster autonomy and independence (including decision making) Patient-centric orientation – foster autonomy and independence (including decision making)

25 Informatics Promote communication/information sharing between providers Promote communication/information sharing between providers Using informatics for patient self- management Using informatics for patient self- management Encourage patients to use informatics to share information with providers Encourage patients to use informatics to share information with providers Identify and build upon existing systems when possible Identify and build upon existing systems when possible

26 Linking Patient and System Continuity of care over time Continuity of care over time Coordination of care across settings Coordination of care across settings Engagement of patient and family Engagement of patient and family Patient-centered assessment and care planning Patient-centered assessment and care planning Collaborative team-based approach Collaborative team-based approach Point-person/liaision Point-person/liaision

27 Journal Supplement J of Gen Intern Med 22(Suppl 3) Dec 2007 J of Gen Intern Med 22(Suppl 3) Dec articles based on background papers and workgroup efforts of the SOTA 9 articles based on background papers and workgroup efforts of the SOTA

28 Research Agenda 1. Advance our understanding of high risk patients with complex chronic illnesses and social complexities, including impact on health care services Multiple chronic illnesses (physical and/or mental), socioeconomic issues (insurance, homelessness), caregiving responsibilities, multiple system users, cultural & literacy issues Multiple chronic illnesses (physical and/or mental), socioeconomic issues (insurance, homelessness), caregiving responsibilities, multiple system users, cultural & literacy issues

29 Research Agenda (cont.) 2. Support new studies/research that will information guidelines which are adaptive to the medical and social complexities of patients with complex chronic conditions Addition of patients to clinical trials who have other conditions/problems beyond the condition of study (less stringent criteria) Addition of patients to clinical trials who have other conditions/problems beyond the condition of study (less stringent criteria)

30 Research Agenda (cont.) 3. Develop and test healthcare system changes that organize care around the medical and social complexities of illness management, including that of the medical home Every person should have access to a medical homea person who serves as a trusted advisor and provider supported by a coordinated team with whom they have a continuous relationship. The medical home promotes prevention; provides care for most problems and serves as the point of first-contact for that care; coordinates care with other providers and community resources when necessary; integrates care across the health system; and provides care and health education in a culturally competent manner in the context of family and community. (AAMC position statement on Medical Home, March 2008) Every person should have access to a medical homea person who serves as a trusted advisor and provider supported by a coordinated team with whom they have a continuous relationship. The medical home promotes prevention; provides care for most problems and serves as the point of first-contact for that care; coordinates care with other providers and community resources when necessary; integrates care across the health system; and provides care and health education in a culturally competent manner in the context of family and community. (AAMC position statement on Medical Home, March 2008)

31 Research Agenda (cont.) 4. Support research that examines best practices in patient-physician communication strategies for care management decisions (e.g., how to prioritize care needs, consideration of other factors that affect care – e.g., family/caregiving responsibilities, living situation/environment, cultural)

32 Research Agenda (cont.) 5.Design and evaluate new informatics strategies to support management of complex chronic care MyHealtheVet MyHealtheVet Telehealth management – web, health buddies, etc. Telehealth management – web, health buddies, etc.

33 Research Agenda (cont.) 6. Examine the role of health care financing for patients with multiple chronic conditions and other complex care needs Issues of dual use Issues of dual use Gaps in coverage Gaps in coverage


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